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Dr. Sangalis an emergency medicine resident in the class of 2019 at the Hospital of the University of Pennsylvania. Dr. Brennanis the chief medical officer and the senior vice president of the University of Pennsylvania Health System and a professor of medicine at the Hospital of the University of Pennsylvania.

Health care is going through a series of transformations, most notable among them the consolidation and merging of health systems. As hospital systems grow, new opportunities will expand resident training and broaden resident perspectives. These new opportunities may shape job searches and increase networking opportunities for graduating residents.

Traditional hub-and-spoke models of a main hospital with a wide referral base have given way to geographic-cluster models to provide advanced care in regional markets. (BMC Health Serv Res 2017;17[Suppl 1]:457; Becker's Hospital Review. Nov. 27, 2012; http://bit.ly/2KfIg3G.) Take the University of Pennsylvania Health System (UPHS) as an example, which has acquired and formed partnerships with Princeton HealthCare System in Plainsboro, NJ; Chester County Hospital in West Chester, PA; and Lancaster General Hospital in Lancaster, PA, over the past few years. These partnerships are not unique to UPHS. Western Pennsylvania hospitals such as the University of Pittsburgh Medical Center and Highmark have moved eastward toward Philadelphia. All these health systems are increasing their referral bases and building economies of scale to increase bargaining power with payers while reducing costs and providing quality on a larger scale. (Becker's Hospital Review. Nov. 27, 2012; http://bit.ly/2KfIg3G; Manag Care 2016;25[9]:24.)

Graduating residents now face a surplus of jobs to choose from, given a physician shortage expected to hit 100,000 doctors by 2030. (Hosp Health Netw 2011;85[12]:12; Merritt Hawkins. 2015; http://bit.ly/2Kf5VBs; AAMC. April 11, 2018; http://bit.ly/2KgzfHK.) Twenty-five percent of physicians changed jobs within three years, and 50 percent of them did so within five. (Plast Reconstr Surg 2011;128[2]:559; NEJM Career Center. http://bit.ly/2KrDMX3.) Senior residents who switched jobs within five years were more likely to prioritize job location compared with physicians staying for more than 10 years at one location, who indicated that they prioritized the quality of the practice. (Merritt Hawkins. 2015; http://bit.ly/2Kf5VBs; Plast Reconstr Surg 2011;128[2]:559; Plast Reconstr Surg 2015;136[1]:96e.) This suggests that graduating residents may not accurately prioritize their needs, and do not explore the culture and quality of practice. (Plast Reconstr Surg 2011;128[2]:559.)

One study found that senior residents were more likely to rank location and teaching as important compared with attending physicians, who ranked salary, incentive structure, and benefits as more important. (Plast Reconstr Surg 2015;136[1]:96e.) Part of this discordance stems from the fact that many residents are entering the job market for the first time, no longer a student or trainee, and now bear primary responsibility for clinical decisions, charting, billing, and leading a team independently. More than 50 percent of 1,200 graduating residents said they received no formal training on issues such as contracts, compensation arrangements, or other employment issues in a 2015 survey. Close to 40 percent felt unprepared for the business side of medicine, while only 10 percent felt prepared. (Merritt Hawkins. 2015; http://bit.ly/2Kf5VBs.) Residents should be encouraged to engage in a wide variety of practice environments during training to gain exposure to different systems and practice styles to help bridge this divide.

I found myself as a senior resident peppered with questions about career aspirations, practice location, and academic versus community medicine. The questions seemed impossible to answer all at one time because the bubble of my institution was the only world of medicine I knew. My residency program offers multiple training sites, yet the culture is the same throughout. When I was told there was a new elective at a large community hospital, I jumped at the opportunity.

New Perspectives

The UPHS and Lancaster General Hospital partnership allowed me to experience a different hospital system. I relocated two hours away from home base for a month, and saw a life outside the bubble. My patients transformed from a young, urban population to Amish octogenarians. I worked with an independent group of EPs who run the ED without residents. I cared for the same diseases I saw in the city, but gained perspective on how differently systems can operate. Anesthesiologists were bedside for critical trauma patients, and critical care teams managed intensive care patients waiting in the ED, unlike in my bubble. The workflow organization was significantly different from anything I had experienced.

I directly handed off patients to inpatient attending physicians, and picked up pearls of wisdom not otherwise gained when handing off to less experienced residents. My home bubble absorbs all the regional transfers, so it was illuminating to be on the other side of transferring patients. I used dictation software, which has forever changed the way I view charting, and maybe most importantly, I gained valuable knowledge about legal issues, billing criteria, and job search processes, and expanded my professional network by working with a new group of attendings.

I am grateful that this opportunity came when it did. Every hospital is different with its own triumphs and challenges, so I encourage other residents to explore beyond the comfortable walls of their home institutions. Spending time at multiple sites broadens your network and connects you with mentors who will provide different perspectives.

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